Discovery University Application DISCOVERY UNIVERSITY APPLICATION Student Application for the 2016 Winter Term. NOTE: All fields are mandatory Name:* First Last Please select the course of interest:*The Geography of Home (Fridays 2:30-4:30pm)Brave New World? Ethical reflections on genetics, biotechnologies and medicine in the 21st century. (Fridays 9:30-11:30am) Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Temporary Address or Contact:Fill this out if you have no permanent address, please list the agency where you are staying, or where you can be contacted. Or, by whom you can be contacted. Phone (Day):*Phone (Night):*Email:* Preferred Method of Contact:*EmailCanada Post Gender:*MaleFemale Date of Birth:* EDUCATIONHighest Completed Grade:* Are you currently in school?*YesNo If not, why did you stop going to school? Have you ever attended university or community college?*YesNo If so, please indicate the years of attendance:If so, what programs/courses did you complete? ADDITIONAL INFORMATIONWill you need bus fare to get to class?*YesNo Are you comfortable speaking and writing in English?*YesNo Can you commit to 5-7 hours per week of study? This includes 2 hours of class time on Fridays.*YesNoThis includes 2 hours of class time on Fridays and 1.5 hours of discussion group time on Wednesday evenings. If possible, would you prefer to be in a discussion group with individuals of your same gender?*YesNo Will you attend the meals provided prior to the discussion groups?*YesNo If so, do you require a vegetarian meal?*YesNo Please indicate any food allergies:* How did you hear about Discovery University?* Can we tell others that you have applied for this course?*YesNo Is this your first time applying to Discovery University?*YesNo If not, how many Discovery University courses have you taken? For statistical purposes, we are collecting data on our students' sources of income. If you are willing to share this information, please state your source of income in the space provided. (e.g. Ontario Works, ODSP, pension, etc.).Source of Income:*WRITTEN STATEMENTPlease write one or two paragraphs explaining why you would like to be a student in the Winter 2016 term. Please note that this writing sample will be used to evaluate your literacy level as well your enthusiasm for the course material. Both first time and repeat students are required to submit a written statement.Please use the space below for your written statement:*PROFESSIONAL REFERENCEIf you have taken a discovery university course before, you are not required to submit a professional reference. For new students, you must submit a professional reference. References must be a professional who knows you well, such as a counselor, agency supervisor, clergy, doctor or case worker. We understand that this information gives us permission to speak with your reference. Please let this person know that you have given us their name and permission to ask about you.Reference name:Reference Phone #:Reference Fax #:Reference's relationship to you: The organizations involved in planning this program are committed to protecting your privacy and maintaining your confidentiality. The information collected will be used for statistical and evaluation purposes only.